Innovative service delivery models overcome barriers to care, advance equity

We at UC Davis Health care deeply about ensuring access to health services and the quality of the care that is delivered. As we know all too well, people who are minoritized or low-income experience disproportionately high rates of preventable disease and premature death, across multiple conditions. 

All too often, members of racial, ethnic and culturally and linguistically diverse communities find health care too difficult to find, too challenging to use, and impossible to afford. For members of these groups, their families and their communities the consequences are severe, medically, socially and economically.

As a result across California, members of underserved populations are in poorer health, suffer worse health outcomes, and have higher morbidity and mortality rates than their white counterparts. For these communities, limited access to needed health services is one of the biggest burdens.

Inequities have been particularly exacerbated during the COVID-19 pandemic. But the response to the pandemic also demonstrated that innovative models of service delivery can effectively increase access to care and utilization of services where people live, work, and play.

The Davis Digital Health Equity Program is a striking example of such a new approach.

This program’s goal is to create a regional public health infrastructure and a model of service delivery to improve access to and continuity of care for historically underserved communities. We are striving to partner with members of our communities, especially with Federally Qualified Heath Centers (FQHCs) like WellSpace Health and Ampla Health, community-based organizations (i.e., Health Education Council), the Mexican Consulate in Sacramento, and other esteemed partners. 

Our digital health equity program:

• has created a regional IT infrastructure to expand UC Davis Health’s ability to partner with FQHCs across the region, bringing expanded health services to historically underserved patients and making access to health care more convenient and feasible.
• is partnering with FQHCs and community-based organizations across the region to join a digital platform that improves care coordination and access to health services where people are at.
• is funding digital health navigators who are helping patients use telehealth services at the point of need.

We started providing free COVID testing on December 2021 under a program called MOVE IT UP, which was supported by a $5 million state grant to the UC Davis Center for Reducing Health Disparities. The locations for our testing clinics were chosen for their proximity to where members of vulnerable populations, including farmworkers, live, work, and congregate. Through this project, we learned the importance of building trust with the communities we are serving, and the importance of becoming trustworthy. 

The MOVE IT UP project goal was to increase the percentage of Latinos and African Americans who are vaccinated, two population groups that have been disproportionally impacted with the highest COVID-19 mortality rates in California. The approach we used was to partner with public health agencies and with trusted community-based organizations, build consistency in the location of the testing clinics and build trust with the community, and match availability of clinics to the community needs.

Below are the vaccinations that we administered by race/ethnicity (N=6,318):

• Hispanic/Latino: 50 percent
• Black or African American: 8 percent
• Asian: 10 percent
• American Indian or Alaska Native: 1 percent
• Native Hawaiian/Pacific Islander: 3 percent
• White: 14 percent
• Other: 14 percent

We nearly doubled (50 percent) the percentage of vaccinated Hispanics/Latinos and increased by one-third (8 percent) the vaccinated African Americans relative to their respective population distribution in Sacramento and Yolo counties (28 percent Hispanic/Latinos and 6 percent African Americans, respectively). This significant increase in vaccinations to Hispanic/Latinos and African Americans was primarily due to the concerted efforts to meaningfully engage particularly these two communities and build trust and become a trustworthy partner.

The Digital Health Equity Program and the MOVE IT UP projects were integrated into what we call the Test-to-Treat Digital Health Equity project, or T2T DHE. We deeply appreciate the support of Congresswoman Doris Matsui who helped secure the funds for this new program. And, this is only just the beginning, as we have plans to provide preventive health screenings by using blood pressure and weight cellular devices and mental health screenings to help underserved populations overcome digital health equity access barriers.

We are also synergizing with the Department of Pediatrics and the Department of Surgery’s efforts to serve underserved populations where they are at as well. We are involving residents, medical students, graduate and other health professions students in this common cause. Armed with resources, including a pediatric mobile van (outfitted with pediatric-friendly exam spaces and counseling rooms), pediatric subspecialists, and child mental health providers, we are exploring ways of partnering with schools and community health centers in remote regions of Northern California to promote the developmental and mental health of children in these communities.

These programs build on the recent Community Health Needs Assessment survey of Sacramento county, in which UC Davis Health stated its commitment to working with community partners and local government agencies to strengthen existing services, and where gaps exist, identify collaborative partnerships and initiatives to better serve at-risk and under-resourced communities. Partnerships matter greatly – as CEO David Lubarsky often says, UC Davis Health “completes, not competes” with our health allies to bring the full spectrum of care to patients, as they are “at the center of everything we do at UC Davis Health.”

Innovating on inequities

The good news is that while the pandemic exposed weaknesses and inequities in health care, it also challenged conventional wisdom and highlighted strengths like innovation, collaboration and the critical importance of meaningful community engagement.

To overcome digital and health inequities of all kinds, a paradigm shift is needed. Historically, health care systems have operated in a “waiting mode,” which means that providers wait for people to come in after symptoms and complications have arisen. A complementary and much needed approach is to set ourselves in a “seeking mode,” whereby we go to our historically underserved communities and intervene before symptoms appear or early in illness, so as to preserve health and normal function for as long as possible. The benefit is clear, as people’s health will be better preserved and they will be able to normally function for longer periods of time, averting the types of crises that emanate from being in the “waiting mode” or delaying care. Everyone should have the opportunity for a healthy life, and the path to health/mental health equity begins with meaningful community engagement.

Meaningful community engagement

A deeper lesson learned is that the path to healthier populations begins by meaningfully engaging members of our communities, and seeking their expertise, wisdom and guidance on the problems of which they are most concerned and identifying the strengths and resilience of their communities and families that have enabled them to persevere, and on which we can build.

Authentic and sustainable community engagement is integral to advancing health equity and being pro-active in serving our vulnerable populations. Community engagement is an ongoing, evolving journey of listening attentively to and engaging in “multidirectional communication” with people about their care and other concerns that matter to them. The process should be engaging, enduring and equitable to all who participate. Building trust is an essential component of meaningful community engagement and requires:

• showing up authentically, being honest, and committing to transparency
• listening
• following through on commitments
• committing to being trustworthy

A foundational component of building trust with communities is demonstrating that community trust is warranted and will not be abused or exploited. In other words, we need as an organization to become trustworthy.

One of the most obvious lessons from the COVID-19 pandemic is that simply informing the public is no longer adequate – effective communication involves listening attentively to what people know and believe, sensing how they feel, and responding to what they do. By reaching out early on to members of our underserved populations, we can help them overcome perceptual, structural, institutional, linguistic and other barriers that keep them from accessing care and being able to maintain health.

The above are examples of how community engagement offers us an evidence-based framework for advancing digital health/mental health equity. Underlying all of this is an institutional cultural change where health systems incorporate the “seeking mode” and go where people live and work.

The Digital Health Equity Program is a notable and much-appreciated effort of our campus, as we seek more effective ways to deliver care to those who too often are left behind.

Finally, there are so many teams, staff and partners I wish to thank for helping us launch and implement our program – too many people and groups to mention individually here (my apologies), so let me emphasize that we are deeply grateful for each and every one of you, especially your hard work, commitment to serve the underserved, and dedication. Your contributions are highly recognized, appreciated and extremely valuable – thank you. Our collective North Star is to serve the underserved.

Yours in health,

Sergio Aguilar-Gaxiola, M.D., Ph.D

Founder and director of the UC Davis Center for Reducing Health Disparities

Director of the Community Engagement Program of the Clinical and Translational Science Center